Integrating Social and Health: Case Catalonia - Juan Carlos Contel

Transcript

1. The journey towards a new model of Integrate health and social care in Catalonia Helsinki, 10th March 2015 “Integrated Care in Practice”
2. The Spanish National Healthcare System •  NHS funded by taxes •  Decentralized to regional autonomies •  Universal coverage •  Free access •  Very wide range of publicly covered services •  Co-payment in pharmaceutical products •  Services provided mainly in public facilities •  Interterritorial Board to coordinate policies
3. Source: IDESCAT, 2015 Ageing in Catalonia 2013-2051 In 2050: 1/3 over 65 y. >12% over 80y.
4. Catalan Healthcare System: some basic features •  Area: 32,106 km2 •  Population: 7,611,711 inhabitants. 17% over 65 y. (expected 32% in 2050) •  1780 € expenditure per capita and 1150 € public expenditure per capita in 2012 •  Life expectancy: 82.27 years •  Gross Mortality rate (2010):8/1,000 inh. •  Infant mortality (2010): 2.6 /1,000 live births •  369 Primary Health Centres (PHC) ranging from 20-45,000 inh) •  69 “acute hospitals” (no far from 50 Km. from every home) •  96 “long term care” centres (residential homes: long-stay, convalescence, pal.liative care) •  41 Mental Health Centres
5. Source:  Catalan  Health  Plan  2011-2015.   The Catalan Health Plan 2011-2015 Health Programs: Better health and quality of life for everyone Transformation of the care models: better quality, accessibility and safety in health procedures Modernisation of the organisational models: a more solid and sustainable health system I   II   III   For  each  line  of  ac.on,  a  series  of  strategic  projects  will  be  developed,  which   make  up  the  31  strategic  projects  of  the  Health  Plan.   9.  Improvements  to  informa(on,  transparency  and  evalua(on   1.  Objec.ves  and  health  programs   7.  Incorpora.on  of  professional  and  clinical  knowledge     6.  New  model  for  contrac(ng  health  care    5.  Greater  focus  on  the  pa.ents  and  families   8.  Improvement  of  the  government  and  par.cipa.on  in  the  system   2.  System   more   oriented   towards   chronic   pa.ents   3.  A  more   responsive   system  from   the  first  levels          More  PHC  !!!   4.  System  with   beOer  quality   in  high-­‐level   special.es   Launched at the end 2011
6. 2.1 Integrated clinical processes 2.2 Protection, promotion and prevention 2.3 Co-responsibility and self- care 2.4 Alternatives in an integrated system 2.5 Complex chronic patients 2.6 Rational prescription and use of drugs Strategic lines of the Chronic Care Program All strategic lines require ICT tools and developments
7. Healthy   33%   Chronic  non  complex   62%   Complex   3,5%   Advanced   1,5%   End  of  life   Bereavement   PREVENTIVE APPROACH CURATIVE APPROACH PALLIATIVE APPROACH SELFCARE COLLABORATIVE CARE Taking care of complex patients
8. •  Integrated Care Pathways as a formal agreement among professional clinical leaders at local level •  Based on reference clinical guidelines and best evidence practice •  Critical key points identification •  Critical variables uploaded at Shared Clinical record •  80% of territories implemented 3 of 4 chronic conditions: COPD, depression, heart failure and DM2. Now Complex Cronic Care Pathways work •  Agreement on different “situations”: 0. Diagnosis, 1. Stable, 2. Acute exacerbation, 3. Management difficulty, 4. Transitional Care, 5. 24/7 guarantee (!) Integrated Care Pathways
9. 9 PCC   Mul(morbidity     Severe  unique  disease   Advanced  frailty   MACA   Limited  live  prognosis   Pallia(ve  approach,     Advance  care  planning   Two profiles of complexity Adhoc labelling: Stratification must be validated by clinicians determining “complex chronic condition and advanced chronic disease” condition
10. -Care centres that have patients classified and marked in these two types, can publish this label/mark in HC3 - The classification / label must be visible on all the screens , given the importance of the condition - It has been incorporated in July 2013 version to HC3 stratification with Clinical Risk Groups (CRGs) PCC: Complex Chronic Patient MACA: Advanced chronic disease
11. “Shared Individual Intervention Plan” (PIIC) ü Health problems/Diagnosis ü Active Medication ü Allergies ü Recommendations for “in case of crisis” or exacerbation ü Advanced Care Planning ü Resources and services used ü Multidimensional assessment ü Carer whom are delegated decisions ü Additional information of interest
12. 9980 1765 11745 64117 12300 76440 92000 28000 120000 0 20000 40000 60000 80000 100000 120000 140000 PCC MACA TOTAL April 2013 Dec 2013 Dec 2014 Initial Health Plan target (!): 25,000 complex chronic patients should be identified by 2015 In January 2015 over 120,000 patients included Evolution in number of PCC and MACA “Labeling” available since January 2013 !
13. Primary Care Information from Centres/Hospitals Specialist Care Diagnostic Procedures Diagnostics Prescriptions Vaccination Hospital Discharge Report A&E Report Specialist Care Report Lab Results RX Report Other diagnostic reports Hospital Data Information from Dep of Health Electronic Prescription Diagnoses Procedures Discharge Data Prescription Medication Plan Shared Clinical Record (HC3)
15. Documents published per year 23.097.493 •  2.119.605 Average documents published per month •  92.262.770 Indexed documents •  6.704.591 Patients with reports 2013 Images > 4 M 2013 Images per day 11.000 Image publication Chronic patients labeled 120.000 PCC and MACA
16. Level 2 Chronic patients at risk Case Management Disease Management Self-care suport Level 1 People with stable chronic diseases at early stage Level 3 Complex chronic patients Comorbidity, emergency hospitalizations, A&E visits, moderate and severe dependency, polypharmacy HEALTH PROMOTION Healthy people WHO do we like to identify people at risk?
17. Multimorbidity unified data base Insured  data  source   NIA,  demographic  data   Diagnosis  data  base   NIA,  .pus_codi,  codi,  data  dx  ,UP,   .pus_UP   “Contact”  data  base   NIA,  dates  contacte  ,UP,  .pus_UP,   urgent,  CatSalut,  T_act.   MDS-­‐Hospital   MDS-­‐PHC   MDS-­‐MH   MDS-­‐NH   MDS-­‐A&E   Central  Registered   Insured     Health  Problems   Pharmacy  (PHC   and  hospital   provided)   Pharmacy  data  base   NIA,  ATC,  data  dispensació,  unitats,   Import   Mortalitat  (INE)   Data  sources   MDS-­‐Social  Services  
18. Multimorbidity in Catalonia obtained by stratification Challenge: It is required to include “social data” to adjust stratification
19. Prevalence of multimorbidity Information available at regional and PHC level
20. Stratification and Emergency admission risk CRG RSC Identification people at risc Proactive measures Classification people at risk Segmentation for the proactive management of people at risk Identification and recording at Clinical Record
21. 1% 18% 133% 10.992€ 13% 13% 2% 7% 57% 5.872€ 13% 26% 8% 3% 28% 3.162€ 28% 54% 17% 1% 14% 1.411€ 25% 79% 72% 0% 2% 282€ 21% 100% POPULATION MORTALITY RATE HOSPITAL. RATE ESTIMATED EXPENSE % ACCUMU- LATED Impact distribution of different segments
22. Visualization in Shared Clinical Record and different RISK scores Morbidity group and RISK calculated and published twice a year Description of different RISK segments
23. Ad-hoc “queries”: Every professional could perform a basic query combining stratification and current chronic conditions and other variables (pharmacy,…) It could be selected 1 or more chronic conditions Stratification segment code
24. Constructing a new GMA morbidity grouper in Catalonia Source: CatSalut, 2013 Mortality PHC contacts Hospitalization A&E use CRG vs GMA CRG vs GMA CRG vs GMA CRG vs GMA
25. Proposal of sharing indicators Indicators Primary Care Hospital Care Social Care Avoidable Hospital Admissions ++ ++ + Home Care program Coverage ++ - ++ Health outcomes: good control, process and treatment ++ ++ Readmission rate in Chronic Obstructive Pulmonary Disease (COPD) and Heart Failure (HF) ++ +++ + COPD/HF Avoidable Hospital Admission ++ ++ Discharge planning in “PRE- Discharge” program ++ - - To ensure continuity care in “POST-Discharge” program - ++ ++ “Quality of life” (HRQoL) assessment ++ ++ ++ Challenge: To aggregate health and social care data
26. SISAP: Professionals System Information You MUST identify an expected prevalence Comparison with Team and all organization Screen display of indicators by doctors and nurses. (!) Monthly data updated !!! Differentiated internal weight among indicators
27. Heart Failure: patients treated with ACE +2,4% last year variation
28. Multidimensional assessment in Home Care +2,6% last year variation
29. Hospital admission by diagnostic groups > 70 y. 0 2000 4000 6000 8000 10000 12000 14000 16000 18000 Hipertensió essencial Deliri, demència i altres trastorns cognitius i amnèsics Trastorns del metabolisme hidroelectrolític Asma Infeccions i ulcera crònica pell Diabetis mellitus amb complicacions Hipertensió amb complicacions i hipertensió secundària Pneumònia per aspiració d'aliments o vòmits Infeccions de vies urinàries Pneumònia (excloent-ne per tuberculosi i MTS) Malaltia pulmonar obstructiva crònica i bronquièctasi Insuficiència cardíaca congestiva 70 and more Pneumonia Source: DGPRS. Dep Salut, 2013 COPD HF Urinary Infection Asthma Diabetes with complications
30. Large differences in emergency hospital admission rates by sector (x 100.000 inhab) 400 600 800 1000 1200 1400 1600 1800 Catalan average: 971 x 100.000 inh.
31. Hospital admissions for chronic conditions Monthly udpated information! Includes: COPD, HF, DM complications, asthma, coronary diseases, HTA Availability of evolution of avoidable emergency admissions for a range of chronic conditions per region / sector / PHC team (x 100.000 inhab. rate) Source: MSIQ, Catsalut −8 % last 24 months 709,6 684,1 652,7 620 630 640 650 660 670 680 690 700 710 720 2011 2012 2013
32. Potentially avoidable hospital admissions for COPD Decrease by 13,1 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of avoidable emergency admissions per region / sector / PHC team (x 100.000 inhab. Tax) Source: MSIQ, Catsalut
33. Potentially avoidable hospital admissions for heart failure Source: MSIQ, CatSalut Decrease by 3 % from Dec 2011 to Dec 2013 (24 months) Availability of evolution of Avoidable Emergency admissions per Region / Sector / PHC Team (x 100.000 inhab. Tax) New trend! Increase by 25% from 2006 till 2011
34. Emergency admissions related to COPD exacerbation More than a half emergency admissions compared to Catalan average (x 100.000 inhab.)  
35. More than a half emergency admissions compared to Catalan average (adjusted data) Emergency admissions related to COPD exacerbation
36. Expected per capita expenditure Average expenditure (€) Primary Care Pharm. Emerg.adm. A&E Outpatient Clinics COPD Diabet. Dement Card. CVA Ment. Cirros. Kidney H. Fail. Neopl. VIH Primary Care Pharmacy Emergency admissions Outpatients clinics
37. Basis for a Social and Health Integrated Care Plan for Catalonia: PIAISS
38. 25th February 2014: New Government Agreement where is launched a new Integrated Health and Social Care Plan in Catalonia Accountable and reporting to Department of Presidency
39. “Microsystems” • Community-based and primary care leadership • Integrated care pathways • Multiprofessional work • Transitional care • Out of hours care • Home care strategy Joint case / care load: Shared needs assessment + action plan Stratification models: assessing population needs Clinical and professional leadership Health and social care local governance Shared outcome framework: shared responsibility & join accountability Aligned incentives: shared vision about the use of resources Shared Electronic Health and Social record Person Empowerment and Self-care ENABLING ELEMENTS Multi-lever approach: ALL things at the same time Culture and change management     Catalonian Integrated Care model: Set of elements to support Integrated Care
40. Shared information systems: constructing a new eClinical and Social care record • Identify the person with the CIP (Identification Number) as a common identifier. • Prior agreement on the coding and register of social problems. • Prepare the local social services information system for it to be ‘interoperable’ in a short-medium term and provide a minimum set of information and variables for a Shared Social and Clinical Record • Access to a minimum set of information and variables of common interest on social field for the Shared Clinical Record of Catalonia (HC3). 1st stage: generation of a Social Intervention Plan incorporated to HC3. 2nd stage: Shared Individual Intervention Plan. • Communication systems to improve accessibility, messaging and virtual work between social and health areas. • Introduce social variables gradually to available health stratification. Challenges to construct and Integrated Health and Social Care record
41. Barcelona project: sharing health and social information PILOT Health Departament with H C C C ( S h a r e d M e d i c a l History of Catalonia) City Council of Barcelona with S I A S ( S o c i a l S e r v i c e I n f o r m a t i o n S y s t e m o f Barcelona). Centres, programs and facilities of health and social care, that are property of the City Council of Barcelona and of the Health Department. Phase 1 : Basic primary social services Phase 2 . Specialist social services WHO IS INVOLVED? PLANNING
42. Legal framework ü  REGULATIONS ü  AGREEMENT The “Framework agreement" has been signed between the Health Department and the City Council of Barcelona concerning the exchange of information among HCCC (Shared Medical History of Catalonia) and Social Service Information System of Barcelona. ü  PERSON CONSENT (!) Informed consent to ask the citizen authorization to share their health and social information. ü  PERSONAL IDENTIFICATION NUMBER The “Personal Identification Number” has been established as the common identifier in health and social systems. Law 12/2007, October 11th, of Social Services and professionals who are involved in the monitoring and evaluation of the citizen. Law 21/2000, September 29th, about the rights of information concerning the health and autonomy of the patient, and clinical documentation. Law 44/2003, Novembre 21th, to regulate profiles of health professions. Agreement GOV / 28/2014 of Febraury 25th, to create the Integrated Health and Social Care Plan (PIAISS), in the Government Plan 2013-2016, to promote, lead and participate in the transformation of the social and health care model to achieve a person-centred integrated care model.
43. Health and social information sharing 43   Category HCCC (Shared Medical History of Catalonia) SIAS (Social Service Information System of Barcelona) ID information Name and surname ID card Date of birth Address Telephones Age Name and surname Gender Date of birth ID card or passport Address Telephones E-mail Census Services information Professionals (general practitioner, nurse) Health centre, palliative care, home care, nursing homes... Professional (social worker) Social services centre Supplementar y information Economic information: pharmaceutical copayment Legal incapacity: process, date, guardian Health information Health factors (diagnostic) Chronically ill categorization Very ill categorization Disability: recognized level, kind of disability, disable scale. Dependent people: recognized level. Risk alert (coronary heart disease, fall s...) Needs assessment Barthel ADL index Lawton-Brody's index Pfeiffer cognitive evaluation test Zarit Burden Interview Barthel ADL index Lawton-Brody's index Pfeiffer cognitive evaluation test Zarit Burden Interview Social risk factors (Health at home - Salut a Casa) Social diagnosis Intervention Individual health intervention plan Individual Treatment Previous medical discharge (24-48 ours before) Medical discharge documents A&E documents EMS (emergency medical services )documents Services: §  Home care services §  Telecare §  Food assistance §  Day care centres Community care Programs/projects Programs/projects
44. “PCC / MACA” condition Shared Individual Intervention Plan (“PIIC”) Diagnostics/ Health problems “Dependency degree” formal assessment “Home Help” services label “Telecare” services label Social Care Intervention Plan Pharmacy prescription Health Care Social Care + Social “Health and Social” Integrated eCare Pilot project in pioneer territories Variables: functional, cognitive deterioration, …. Variables: functional, cognitive deterioration, ….
45. A Web Service is a method of communication between two electronic devices over a network. This will be the way to share information between HCCC (Shared Medical History of Catalonia) and SIAS (Social Service Information System of Barcelona).     Security Common repository à Informed consent will be signed by the citizen. à The health or social professional will send the document to the common repository . à Each professional can check if the citizen has signed this consent. à Informed consent will be custodied in a common repository. à It will be validated by both systems. à It will do periodic checks. Send  informa.on   Receive  informa.on   Send informed consent and check Technological terms Health Departament Information System Social Service Information System
46. RISK TO DEVELOP COMPLEX HEALTH AND SOCIAL NEEDS COMPLEX HEALTH AND SOCIAL NEEDS HIGH HEALTH AND SOCIAL COMPLEXITY 1 2 3 4 5 6 7 Complex health and social needs ? The need of incorporating Social Services in the definition of a JOINT Care Plan
47. Shared needs assessment instrument 2 alternative options to be decided: 1. To adapt a validated commercial solution: interRAI, SMAF,… 2. To construct a shared need assessment instrument based on professional consensus *It is required to facilitate collaborative environment between professionals working in different areas of health and social services
48. NEW SHARED INTERVENTION PLAN (PIIC) • Diagnostics • Medication Plan • Allergies • Recommendations in case of CRISIS or acute exacerbations: dyspnea, pain, fever, behavior change • Advanced Care Planning: preferences, values, therapeutic adequacy • Multidimensional Assessment: functional, cognitive and social risk • Social Services utilization: Home care, Home help, telecare, case management • Emergency admissions and A&E visits in last 12 months • Living alone ? • Carer information
49. i-SISS.Cat Strategic plan for the implementation and deployment of the platform for the management of healthcare and social care Processes in Catalonia
50. The i-SISS.Cat solution overview: 360º PERSON VISION GLOBAL CARE PLAN COLLABORATION  ENVIRONMENT
51. Integrated Care Complex Care Pathway with Social Services PHC Sever. Referral Appointment Results   PHC Sec Care PHC To plan appointment Treatment     response   Sec.  Care   Good Appointment   Bad Results HF     confirma(on   Appointment Outpatient No  HF     confirma(on   Priority PHC Yes No Stable Yes No Appointment Outpatient Admission
52. “Personal Health Folder” Cat @Salut “La Meva Salut”
53. “Microsystems” • Community-based and primary care leadership • Integrated care pathways • Multiprofessional work • Transitional care • Out of hours care • Home care strategy Joint case / care load: Shared needs assessment + action plan Stratification models: assessing population needs Clinical and professional leadership Health and social care local governance Shared outcome framework: shared responsibility & join accountability Aligned incentives: shared vision about the use of resources Shared Electronic Health and Social record Person Empowerment and Self-care ENABLING ELEMENTS Multi-lever approach: ALL things at the same time Culture and change management     Catalonian Integrated Care model: Set of elements to support Integrated Care
54. gencat.cat